Download Patient Care Process Assessment: Information Gathering

The Patient Care Process
Assessment: Part I Information Gathering
Lalitha Raman-Wilms, PharmD, FCSHP
Associate Professor
Leslie Dan Faculty of Pharmacy
University of Toronto
Session II
• Part I: Assessment: Information
Gathering
• Part II Assessment: Pharmacotherapy
Work-up
• Part III Care Plan & Follow-up Evaluation
Learning Objectives: Part I
• Describe how patients’ medication taking
experience relates to their drug-related needs
• List the specific types of information to be
gathered in order to assess patients’ drug
therapy
• Describe how patients’ Current Medication
Record should be documented
• List the specific types of information related to
the past medication history which should be
considered in the management of current
conditions
• Describe what information should be included in
a Current Review of Systems
Pharmaceutical Care Practice:
How does a pharmacist provide this care?
• With a patient-centered approach: patient’s drug-related
needs drive practice – START WITH THE PATIENT
• Use a consistent process in providing this care – called
the PATIENT CARE PROCESS
• Identify and resolve patients’ DRUG THERAPY
PROBLEMS
• DOCUMENT this care in an efficient & usable manner
• Work with the patient’s HEALTH CARE TEAM
Patient Care
1
Process
• Assessment
Of patient’s drug-related needs
Identify problems related to drug therapy
Establish a trusting
relationship
• Care Plan
Address identified drug therapy problems and
work to achieving goals for each condition
• Follow-up evaluation
Ensure goals are met; no new problems
related to drug therapy
1Pharmaceutical
Care Practice, 2004, Cipolle et al
Continuous follow-up
ASSESSMENT
Assessment of Drug Therapy1
Activities
Responsibilities
Meet the patient
Establish the therapeutic
relationship i.e. develop an
effective relationship with the
patient
Elicit relevant information from
patient (& the patient’s chart &
other health care professionals)
Determine who pt is, reason for
encounter, demographics,
medication experience, and other
clinical information i.e. GATHER
THE RELEVANT INFORMATION
Make rational drug therapy
decisions using the
Pharmacotherapy Workup
Are patient’s drug-related needs
being met?
Identify drug therapy problems
1Pharmaceutical
Care Practice 2004, Cipolle, Strand, Morley, The Patient Care
Process, page 11.
Patient-Pharmacist Relationship
• Based on: Mutual respect, Trust, Open
Communication, Cooperation, Mutual
Decision Making
– Essential clinical skills: inquiry, listening, and
observational skills
– Effective use pharmacotherapeutic knowledge
– Practitioner must collect information and
make clinical decisions, in partnership with
the patient
– Work collaboratively with patient’s other
health care providers to optimize care
Assessment of Drug Therapy1
Activities
Meet the patient
Responsibilities
Establish the therapeutic relationship
i.e. develop a trusting relationship
with the patient
Elicit relevant information from Determine who pt is, reason for
patient
encounter, demographics, medication
experience, and other clinical
information i.e. GATHER THE
RELEVANT INFORMATION
Make rational drug therapy
decisions using the
Pharmacotherapy Workup
1Pharmaceutical
Are patient’s drug-related needs being
met?
Identify drug therapy problems
Care Practice 2004, Cipolle, Strand, Morley, The Patient
Care Process, page 11.
Patient’s medication experience
• Their general attitude toward medications; their
understanding and expectations of their medications
– e.g. ‘natural remedies like herbs are safer; I don’t like
medications’
– Consider patient’s cultural, health care beliefs
• ‘Patient concerns
– ‘This medication has a lot of side effects and I am not
sure I want to take it; maybe I can take it only when I
need it’
What is your understanding of your medications?
What do you expect from your medications?
What are your concerns about your medications?
Responses
• Why are they taking the medication?
– Relates to the need for drug therapy:
• Is the drug indicated?
• What are their expectations?
– What they think the drug will do for them
• Is the drug effective?
• What are their concerns?
– What are they concerned the drug may do?
• Is the drug safe?
All of the above determine if the individual will take
the drug!
Responses
• Why are they taking the medication?
– Relates to the need for drug therapy:
• Is the drug indicated?
INDICATION
• What were their expectations?
– What they think the drug will do for them
• Is the drug effective?
EFFECTIVENESS
• What were their concerns?
– What are they concerned the drug may do?
• Is the drug safe?
SAFETY
All of the above determine if the individual will take
the drug!
Drug-related needs
• Individual’s understanding of why they are taking
their medications
• Their expectations related to their medications
• Their concerns related to their medications
TRANSLATE INTO PATIENT’S DRUG-RELATED
NEEDS
Patient’s drug-related needs
• Understanding of their
medications
• INDICATION
• Expectations of
medications
• EFFECTIVENESS
• Concerns related to their
medications
• SAFETY
• Are they able to take it as
appropriate?
• COMPLIANCE /
ADHERENCE
Information Gathering:
• Reason for the encounter / main complaint
• Patient Demographics (age,ht, wt, living
situation)
• Patient’s understanding, expectations &
concerns
• Current medications & conditions
• Past medications & conditions (allergies,
immunizations, what worked well, what did not
and why)
• Medication-related review of systems
Information Gathering:
Patient, Disease and
Drug Information
Drug Therapy Problems
Prioritize
1. Reason for the encounter /
main complaint
2. Patient Demographics
3. Patient’s understanding,
expectations & concerns
4. Current medications &
conditions
5. Past medications &
conditions (allergies,
immunizations, what
worked well, what did not
and why)
6. Medication-related review
of systems
4. Current Medication Record
• All current medications used by the patient
– This includes prescribed drugs, OTC products,
herbals and vitamins which may be self-selected by
the patient and topical products
• Information should include generic drug name,
dose, frequency, duration if appropriate
• Consider how best to organize this
information to enable clinical decision on its
effectiveness & safety
The Current Medication Record
• INDICATION – the reason the patient is
taking the medication
• DRUG PRODUCT – includes the drug
name, the dosage strength
• DOSAGE REGIMEN – the dose, the
frequency of administration, the route
• START DATE – when patient started to
take the medication
• RESPONSE – includes both positive
effects and negative effects of drug
therapy
The Current Medication Record
Effectiveness
Indication
Drug product
Dosage regimen
Outcomes
Safety
Figure 7-1
Organization of Current Medication
Record
Indication
Hypertension
Drug
Dosage
Product Regimen
25 mg po
chlorothiazide qam
Hydro-
Outcome
BP
135/85
4. Organization of Current
Medication Record
Indication
Drug
Product
Dosage
Regimen
hypertension Hydrochloro- 25 mg po
thiazide
qam
Start
Date
Jan 3,
2012
Outcomes:
Effectiveness
/ Safety
BP: 135/85
No reported side
effects
5. Past Medication History
• Understanding of effectiveness and safety
concerns from past use
• Allergies, Adverse Drug Reactions,
Immunizations, special needs (can’t
swallow large pills), use of caffeine,
tobacco, etc., what worked & what did not
work previously and why
• Usually discussed during the patient’s first
encounter with the pharmacist
6. Information GatheringReview of Systems
Review of Systems:
• Vital signs: BP,
Temp, HR, RR
• Head/Neurological:
Psychological
• EENT
• CV
• Pulmonary
• Fluid/Electrolyte
•
•
•
•
•
•
Hepatic
Endocrine
Hematology
Gastrointestinal
urology/reproductive
Musculoskeletal
Skin
Information Gathering:
Patient, Disease and
Drug Information
Drug Therapy Problems
Prioritize
1. Reason for the encounter /
main complaint
2. Patient Demographics
3. Patient’s understanding,
expectations & concerns
4. Current medications &
conditions
5. Past medications &
conditions (allergies,
immunizations, what
worked well, what did not
and why)
6. Medication-related review
of systems
Information Gathering
Only collect information which is
needed now to assess the patient’s
drug-related needs and identify drug
therapy problems.
The main area to focus on is the
patient’s primary problems or
concerns.
Learning Objectives: Part I
• Describe how patients’ medication taking
experience relates to their drug-related needs
• List the specific types of information to be
gathered in order to assess patients’ drug
therapy
• Describe how patients’ Current Medication
Record should be documented
• List the specific types of information related to
the past medication history of patients which
should be considered in the management of
current conditions
• Describe what information should be included in
a Current Review of Systems